Slide 1

Dr. Monika Madaan Specialist Dept. Of Obstetrics & Gynaecology ESI Hospital Manesar Slide 2 PPH Single most important cause of maternal mortality worldwide. Accounts for 34% of maternal deaths in developing countries. Slide 3 Definition Any blood loss than has potential to produce or produces hemodynamic instability Slide 4 Definition Blood loss > 500 ml after delivery Primary : Loss within 1 st 24 hours after delivery Secondary : 24 hours till 12 weeks postnatally Minor : 500-1000 ml Moderate : 1000-2000 ml Severe : > 2000 ml Slide 5 PREDICTION AND PREVENTION Identify pt. at risk - Pl previa/accreta - Anticoagulation Rx - Coagulopathy - Overdistended uterus - Grand multiparity - Abn labor pattern - Chorioamnionitis - Large myomas - Previous history of PPH Slide 6 PREDICTION AND PREVENTION Active Management Of Third Stage Of Labor (AMTSL): Should be offered routinely and includes: 1. Administration of uterotonics soon after birth. 2. Delayed cord clamping. 3. Delivery of placenta by controlled cord traction followed by uterine massage. Slide 7 PPH Drill Clear and logical sequence of steps essential in the management of PPH. Slide 8 CALL FOR HELP Slide 9 Team Effort Skilled Obstetric Team Trained Anaesthesiologist Clinical hematologist Supporting staff Slide 10 Resuscitation Assess A : Airway B : Breathing C : Circulation Secure 2 wide bore i.v. lines:- 14-16 gauge Draw blood for grouping & cross matching, CBC, LFT/KFT, SE & Coagulogram. Slide 11 Position flat Keep the patient warm Administer oxygen by mask ( @ 10-15 litres/ min) Catheterize the patient for emptying bladder & monitoring output Slide 12 Fluid Replacement RAPID WARMED infusion of fluids Crystalloids : Fluids of choice until compatible blood is arranged 1 ml of blood loss= 3 ml of crystalloids Total volume of 3.5 litres of clear fluids (upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood. Slide 13 If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given Slide 14 FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal (ie 12-15 ml/kg or total of 1 litres.) Platelet Concentrate: if Platelet count< 50,000/ microlitre. Cryoprecipitate: if fibrinogen < 1 g/ l. Slide 15 Continuous vital monitoring. Monitor adequacy of replacement with urine output (0.5 ml/kg/hr) and CVP (4-8 cm water) Main therapeutic goals are to maintain: Haemoglobin > 8gm/dl Platelet count > 75 10 9 / l Prothrombin < 1.5 mean control APTT < 1.5 mean control Fibrinogen > 1 gm/ l Slide 16 Establish Etiology Simultaneously 4 Ts Tone (abnormalities of uterine contraction) : 70 80% Trauma (of the genital tract) : 20 % Tissue (retained products of conception) : 10 % Thrombin (abnormalities of coagulation) : 1 % Slide 17 Contd Check tone of uteruswell contractedSuspect trauma Explore cervix and vagina Slide 18 Bimanual Compression If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions Slide 19 Administer Uterotonic Drugs FIRST LINE Oxytocin: Start with 5 units slow iv or im. Infusion of 20 units in 1 L@ 60 dr/min. Continue same dose @ 40 dr/min until bleeding stops. Maximum upto 3 L. SECOND LINE Ergometrine/ methyl ergometrine: Dose: 0.2 mg im or slow iv Repeat 0.2 mg after 15 min. Maximum 5 doses (1 mg) Syntometrine im Slide 20 THIRD LINE PGF 2: Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. Misoprostol: 200-800 g sublingually. Do not exceed 800 g WHO GUIDELINES FOR MANAGEMENT OF PPH 2009 Slide 21 Uterine Tamponade Bakri balloon Sengstaken Blakemore oesophageal catheter Condom catheter Urological Rusch balloon Success depends upon Positive Tamponade test Slide 22 Procedure of condom Balloon insertion Initial Assembly Condoms-2 Foleys catheter-no.16 Saline with iv set Speculum Sponge holding forceps Slide 23 Procedure Lithotomy position Indwelling Foleys catheter. Explore uterus, cervix and vagina. Inflate balloon with 100- 300 ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test). Slide 24 Compression sutures B Lynch Suture Fundal compression suture Apposes anterior & posterior wall Slide 25 Contd Parallel Vertical compression sutures for placenta praevia Slide 26 Stepwise Uterine Devascularization Uterine arteries Tubal branch of ovarian artery Internal iliac artery Slide 27 Uterine Artery Embolization Possible only if internal artery ligation has not been done and facility for interventional radiology available Slide 28 Hysterectomy Resort to hysterectomy SOONER RATHER THAN LATER High maternal morbidity Timing and adequate replacement is of utmost importance Slide 29 Documentation and Debriefing Important to record: Sequence of events Time and sequence of admn of pharmacological agents, fluids, blood products The time of surgical intervention The condition of mother throughout. Slide 30 Newer Developments Tranexamic acid : 1 gm i.v slow. Can be repeated after 30 min if bleeding continues./ Recombinant activated factor VII (Novoseven): 90 g/ kg. May be repeated within 15-30 minutes. No clear consensus on efficacy. Carbetocin (oxytocin agonist) : 100 g i.v or i.m. Produces tetanic uterine contractions. Slide 31 HAEMOSTASIS ALGORITHM H Ask for help A Assess and resuscitate E Establish etiology M Massage the uterus O Oxytocic administration S Shift to OT T Tissue n trauma to be excluded and proceed to tamponade A Apply compression sutures S Systematic pelvic devascularisation I Interventional radiology S Subtotal or total hysterectomy Slide 32 To Conclude, Management of PPH Has Evolved From: Panic Hysterectomy Pitocin Prostaglandins Happiness Slide 33